The Equation of Suicidal Intent, which was introduced in Part 1 of this 2-part series, postulates that the real suicidal intent of any given patient may be equal to any one of the following or a combination of the following1:

• Stated intent: what the patient directly tells the clinician about his or her suicidal intent

• Reflected intent: the amount of thinking, planning, or actions taken on suicidal ideation that may reflect the intensity of the actual suicidal intent

• Withheld intent: suicidal intent that is unconsciously or purposefully withheld from the clinician

Reflected intent was defined as the quality and quantity of the patient’s suicidal thoughts, desires, plans, and extent of action taken on those plans, which may reflect how much the patient truly wants to commit suicide. The extent, thoroughness, and time spent by the patient on suicidal planning may, not in all, but in some patients be a better reflection of the seriousness of their intent and the proximity of their desire to proceed on that intent than the patient’s actual stated intent. Such reflections of intent may prove to be lifesaving pieces of the suicide assessment puzzle.

The interviewing strategy known as the Chronological Assessment of Suicide Events (the CASE Approach) was designed to minimize the likelihood that at the time of risk formulation, such essential pieces of the puzzle would be missing. The goal was to create a practical interviewing strategy that could be reliably used to maximize the validity of the patient’s stated and reflected intent while minimizing withheld intent—no matter how tired or overwhelmed the clinician might be or how hectic the clinical environment may have become. The ultimate goal of the interviewing strategy is to help the clinician determine the patient’s actual suicidal intent.

Key design elements and development

The CASE Approach is a flexible, practical, and easily learned interviewing strategy for eliciting suicidal ideation, planning, behavior, desire, and intent. It was developed to help the clinician explore both the patient’s inner pain and the suicidal planning that often reflects this pain. It was specifically designed to help transform the hindrances that often block the open sharing of suicidal intent. Used effectively, it may lead a seriously dangerous patient—predisposed to withhold his suicidal intent—to share his intent. It may also help clinicians to determine more accurately the dangerousness of a patient by bringing to the surface hidden elements of the patient’s reflected intent.

For clinicians, the practical problems related to uncovering a valid history of suicidal ideation, behaviors, desire, and intent are compounded by the hectic clinical settings of contemporary practice. The time constraints related to managed care pressures, the increased workloads necessitated by down-staffing, and an increasingly litigious society combine to place additional pressures on clinicians who may already be under considerable stress.

Moreover, complicated suicide assessments have a knack for occurring at the “wrong” times: in the middle of an extremely hectic clinic day or in the chaotic environment of a packed emergency department (ED) or crisis line center. And the stakes are high. An error can result in not only an unnecessary death—a terrible tragedy—but also in a lawsuit, much less important but very disturbing in its own right. In many suicide assessment scenarios, we find a harried clinician performing a difficult task, under extreme pressure, in an unforgiving environment. No wonder mistakes are made.